Basic Information
Provider Information | |||||||||
NPI: | 1578094207 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | BRAD | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3889 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376023889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234792457 | ||||||||
FaxNumber: | 2342839480 | ||||||||
Practice Location | |||||||||
Address1: | 301 MED TECH PKWY STE 240 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376042641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237945520 | ||||||||
FaxNumber: | 4232826940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2017 | ||||||||
LastUpdateDate: | 05/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 194218 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 22515 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.